Nokea
A 6-month-old infant is diagnosed with cystic fibrosis. What explanation should the nurse provide to the parents about this condition?
- A. It is a condition affecting the respiratory and digestive systems.
- B. It is an autoimmune disorder affecting multiple organs.
- C. It is a genetic disorder that can be managed with medication.
- D. It is a condition caused by prenatal exposure to toxins.
Correct Answer: A
Rationale: The correct answer is A: 'It is a condition affecting the respiratory and digestive systems.' Cystic fibrosis is a genetic disorder that primarily affects the respiratory and digestive systems. It is caused by a defective gene that leads to the production of thick and sticky mucus in these organs. This mucus can clog airways in the lungs and block the ducts in the pancreas, affecting digestion. Choice B is incorrect because cystic fibrosis is not an autoimmune disorder; it is a genetic condition. Choice C is partially correct in that cystic fibrosis is a genetic disorder, but merely managing it with medication oversimplifies the comprehensive care needed for individuals with cystic fibrosis. Choice D is incorrect as cystic fibrosis is not caused by prenatal exposure to toxins but is a genetic condition inherited from parents.
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The parent of a 2-year-old child is informed by the nurse that the toddler's negativism is expected at this age. What need is this behavior meeting?
- A. Trust
- B. Attention
- C. Discipline
- D. Independence
Correct Answer: D
Rationale: Negativism in toddlers commonly occurs around the age of 2 as they begin to assert their independence and autonomy. At this stage, children are exploring their own will and preferences, leading to behaviors like defiance or negativism. Independence (choice D) is the primary need being met by this behavior as toddlers strive to establish their individuality and decision-making. While trust (choice A) is crucial for forming secure attachments, it is not the main need driving negativism in this case. Seeking attention (choice B) may be a behavior exhibited by children, but it is not the fundamental need being fulfilled by negativism. Discipline (choice C) is important for setting boundaries and teaching appropriate conduct, but it is not the primary need being addressed by negativism in toddlers.
A child is admitted with extensive burns. The nurse notes burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has a(n)
- A. chemical burn
- B. inhalation injury
- C. electrical burn
- D. hot-water scald
Correct Answer: B
Rationale: Burns on the lips and singed nasal hairs are indicative of an inhalation injury. This suggests that the child has likely inhaled hot gases or smoke, leading to damage in the respiratory tract. Choice A, chemical burn, is incorrect because the symptoms described are more aligned with inhalation rather than direct contact with chemicals. Choice C, electrical burn, is incorrect as there are no mentions of contact with an electrical source. Choice D, hot-water scald, is also incorrect as the presentation of burns on the lips and singed nasal hairs is not characteristic of scald injuries.
The nurse is reviewing the laboratory test results of a child diagnosed with disseminated intravascular coagulation (DIC). What would the nurse interpret as indicative of this disorder?
- A. Shortened prothrombin time
- B. Increased fibrinogen level
- C. Positive fibrin split products
- D. Increased platelets
Correct Answer: C
Rationale: Positive fibrin split products indicate disseminated intravascular coagulation (DIC), a condition characterized by the widespread formation of blood clots throughout the body. In DIC, clotting factors are consumed, leading to increased fibrin split products. A shortened prothrombin time (Choice A) is not typically seen in DIC as it indicates faster blood clotting, which is not consistent with the pathophysiology of DIC. An increased fibrinogen level (Choice B) is also not a characteristic finding in DIC, as fibrinogen levels may be decreased due to consumption in the formation of clots. Increased platelets (Choice D) are not typically observed in DIC; instead, thrombocytopenia (decreased platelet count) is more common due to their consumption in clot formation.
A child is being assessed for suspected intussusception. What clinical manifestation is the nurse likely to observe?
- A. Projectile vomiting
- B. Currant jelly stools
- C. Abdominal distension
- D. Constipation
Correct Answer: C
Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (Choice B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (Choice A) is more commonly associated with conditions like pyloric stenosis. Constipation (Choice D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.
When counseling a couple who suspect they could have a child with a genetic abnormality, what would be most important for the nurse to incorporate into the plan of care when working with this family?
- A. Gathering information from at least three generations
- B. Informing the family of the need for a wide range of information
- C. Maintaining the confidentiality of the information
- D. Presenting the information in a nondirective manner
Correct Answer: D
Rationale: When counseling a couple about the possibility of having a child with a genetic abnormality, it is vital for the nurse to present information in a nondirective manner. This approach empowers the couple to make decisions based on their values and preferences, respecting their autonomy. Gathering information from three generations (Choice A) may not be necessary and might overwhelm the couple with unnecessary data. Informing the family about the need for a wide range of information (Choice B) is not as critical as supporting their decision-making process through a nondirective approach. While maintaining confidentiality (Choice C) is crucial, it is not the most important aspect compared to ensuring the couple can make informed choices that align with their beliefs and wishes.